World Health Organization. Western Pacific Region

Transcription

1 Basic modules for hepatitis 1

2 Basic Module 1 Liver anatomy and physiology 2

3 Position of liver Midline Located in right upper abdomen Protected by the right rib cage Right upper Measures: cm in vertical direction Weight: ~1500 grams Two lobes Left upper Umbilical line Right: Extends till near the right costal margin (the lower edge of the rib cage) Left: Extends midway between xiphisternum and umbilicus Right lower Left lower 3

4 Several functions, including some of the following Glucose metabolism During the feeding phase Move glucose into glycogen stores (liver) During fasting Move sugar from stores (liver) to the blood Excretory function Bile pigments (bilirubin) Bile salts Important for absorption of fats Other harmful substances (detoxication) Synthetic function Albumin Coagulation factors Functions of the liver 4

5 Basic Module 2 Laboratory test in liver diseases 5

6 Common tests of liver function Test Normal values Purpose Total bilirubin mg/dl <2.0 Conjugation, Conjug. Bilirubin mg/dl <15% of total bilirubin excretion ALT/SGPT IU/L <40 Enzymes released by liver AST/SGOT IU/L <40 cell injury/death Alk.phosphatase Varies by method Enzymes released by biliary GGT IU/L <35 injury or obstruction Albumin g/dl Synthetic function Prothrombin time INR The reference ranges for these tests may vary slightly between laboratories and populations 6

7 Assessing the liver disease severity Chronic hepatitis Liver cirrhosis (compensated) Liver cirrhosis (decompensated) Liver failure 7

8 Basic Module 3 Symptoms and Signs of liver disease 8

9 Glycogenesis & Gluconeogenesis Features of liver failure Poor glycogen store > hypoglycemia > hyperglycemia Poor gluconeogenesis > hypoglycemia Excretory function Bile pigment Impaired excretion > Jaundice Synthetic function Albumin Coagulation factors > Hypoalbuminemia > edema/ascites > Prolonged prothrombin time (INR) 9

10 Other signs Dark skin pigmentation Palmar erythema Palmar erythema Vascular spider Xanthoma Subcutaneous bleed Spider angiomas Gynecomastia 10

11 Basic Module 4 Introduction of viral hepatitis 11

12 What is hepatitis? Definitions Hepatitis: Inflammation of liver Acute hepatitis: Hepatitis usually recovered < 3 months Chronic hepatitis: Hepatitis continuing for > 6 months 12

13 Cause of hepatitis Hepatitis viruses infection (HAV, HBV, HCV, HDV, HEV) Other infections Viruses other than hepatitis viruses (e.g. CMV, EBV, ) Parasites (e.g. malaria) Bacteria (e.g. typhoid) Toxic substances (Alcohol, Aflatoxin, ) Autoimmune disease Ischemia (reduced blood supply) 13

14 Main hepatitis viruses Hepatitis A virus (HAV) Hepatitis E virus (HEV) Hepatitis D virus (HDV) Hepatitis B virus (HBV) Hepatitis C virus (HCV) Chronic infection Liver cirrhosis Liver cancer 14

15 Acute hepatitis HAV HBV HCV HDV HEV Case fatality Case fatality Uncommon increases with increases with age age Superinfection in HBV may lead to fulminant disease Higher case fatality in pregnant women Chronic No 5% (adults) 55 85% Very rare infection 90% (children) Complicates hepatitis B HCC* No Yes Yes No Route of transmission Waterborne Foodborne Person to person Main hepatitis viruses Perinatal Bloodborne Sexual Bloodborne Perinatal Sexual Bloodborne Waterborne Foodborne Vaccine Yes Yes No HBV vaccine No Treatment None options None Available Available Modified treatment of HBV *HCC; hepatocellular carcinoma 15

16 Acute hepatitis and chronic hepatitis Acute hepatitis Chronic hepatitis Definition Usually recovered <3months Continuing for > 6months Etiology HBV, HEV, HAV, HBV, HCV, Alcohol, Symptom Sequela Almost no symptom or jaundice, dark urine, general fatigue, abdominal pain, Acute liver failure Almost no symptom or ascites, edema, jaundice, (decompensated liver cirrhosis) Liver cirrhosis Chronic liver failure Hepatocellular carcinoma Esophageal varices Findings 16

17 Liver cirrhosis and hepatocellular carcinoma Liver cirrhosis is an advanced stage of chronic hepatitis Chronic hepatitis Liver cirrhosis (compensated) Liver cirrhosis (decompensated) Liver failure Ascites, edema, variceal hemorrhage, encephalopathy, jaundice, death Hepatocellular carcinoma 17

18 Basic Module 5 Burden of viral hepatitis 18

19 Hepatitis mortality is increasing 1.34 million deaths from viral hepatitis in th leading cause of death among all cause mortality 2 Millions of deaths Hepatitis Tuberculosis HIV Malaria Year 1.34 million deaths in % hepatitis deaths from HBV and HCV (cirrhosis and hepatocellular carcinoma) 19 Sources WHO Global hepatitis report 2017

20 Regional distribution of hepatitis deaths WHO Global health sector strategy on viral hepatitis

21 Comparison of global and Western Pacific mortality 21 GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age sex specific all cause and cause specific mortality for 240 causes of death, : a systematic analysis for the Global Burden of Disease Study Lancet Jan 10;385(9963):

22 Hepatitis deaths in Liver cancer is second most common cause of deaths. 78% of liver cancer are due to HBV or HCV. (2015) 22

23 Global epidemiology of Hepatitis B infection 240 million people around the world infected with HBV 680,000 die every year due to hepatitis B Children 5 9 years, 2005 Adults years, Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection. WHO: 2015 ( b guidelines/en/)

24 240 million of adults years of age living with HBV infection (HBsAg) worldwide, 2005 Sources Ott J et al, Vaccine, 2012 WHO Global health sector strategy on viral hepatitis

25 Global epidemiology of Hepatitis C infection 80 million people around the world infected with HCV 700,000 die every year due to hepatitis C 25 Guidelines for the screening, care and treatment of persons with chronic hepatitis C infection. Updated version, April WHO; 2016 ( c guidelines 2016/en/)